A test of the maturation hypothesis with respect to opiate addiction

Sections

The Addict Sample
Sources of Data and Measures
Findings
Addiction Status at Time of Interview
TABLE I Years spent addicted, in prison, and abstinent from onset of opiate use to 1964 for three addicted groups and one cured group
Criminality and Maturation
TABLE 2 Number of arrests while addicted and while abstinent for three addicted groups and one cured group
TABLE 3 Criminality during first three years following onset and during last three years for cured and addicted patients
Principal Employment
Discussion
Conclusion

Details

Author: John C. BALL, Richard W SNARR
Pages: 9 to 13
Creation Date: 1969/01/01

A test of the maturation hypothesis with respect to opiate addiction

, Ph.D. John C. BALL
Professor, Department of Psychiatry, Temple University and . , M.A. Richard W SNARR
Assistant Professor, Eastern Kentucky University

Two contrary positions have been advanced with respect to the life course of opiate addiction in the United States. On the one hand, it has been maintained that the opiate addict is incurable. He is held to have an invariable tendency to relapse following treatment, because of a psychological dependency or craving, which accompany addiction. Thus, following the onset of physical dependence his way of life becomes increasingly oriented around securing drugs and he usually pursues a non-productive or deviant role in society. He does not voluntarily seek medical treatment or rehabilitation, and he returns to opiate use soon after involuntary institutionalization, often the same day that he is discharged. The dynamics of this compulsion to use drugs is seen as based upon operant conditioning [ (11)] , craving [ (6)] , mental illness [ (5)] or social factors [ (4)] . But whatever the dynamics, the life course of opiate addiction is considered to be irremediable.

The second viewpoint concerning opiate addiction is that many addicts give up their dependence on drugs as a result of maturation, as a consequence of treatment, or through remission of the disease [ (7)] . In this view, it is usually recognized that while some of the " hard core " opiate addicts cannot be rehabilitated, most addicts can and do give up their drug-centred way of life. They do become abstinent, either by design, persuasion, or by dint of circumstance.

The particular question under investigation in the present study concerns the maturation hypothesis postulated by Charles Winick in 1962 [ (12)] . Following a statistical analysis of the File of Active Addicts of the Bureau of Narcotics, he concluded that some two-thirds of the opiate addicts in the United States " mature out " of their addiction during their adult years. Winick's hypothesis is provocative. It was decided to employ the findings from a follow-up field study of opiate addicts to test the maturation hypothesis.

The Addict Sample

A follow-up study of 242 former addict patients at the Lexington Hospital was undertaken in Puerto Rico during 1962-1964. The field experiences in Puerto Rico have been described elsewhere and the validity of the interview data established ( [ 1] , [ 3] ).

The 242 subjects included all addicts admitted to the U.S. Public Health Service Hospital at Lexington between 1935 and 1962 who were residents of Puerto Rico. Post-hospital information was obtained for 98 % of the subjects. Of the 242 former addicts, 122 were located and interviewed. All but a few of those not interviewed were dead, had migrated from Puerto Rico, or were serving long terms in continental prisons. The information concerning these subjects who could not be interviewed was often extensive and quite satisfactory for descriptive purposes, but it was not of sufficient uniformity to enable the type of detailed life history comparison required to test the maturation hypothesis. The present study is confined to the 108 male opiate addicts who were specifically interviewed with respect to their drug history, treatment, criminality and employment careers.

Sources of Data and Measures

The following sources of data were utilized in the study: ( a) medical records at the Lexington Hospital; ( b) hospital, police and penal records in Puerto Rico; ( c) hospital and prison records in the United States; ( d) FBI arrest history up to 31 October 1964 (federal prisoners only); ( e) Bureau of Narcotics Records; ( f) interviews with relatives and friends; ( g) interview of subject; ( h) analysis of urine specimen; and ( i) such other sources as newspaper accounts and death certificates.

From the available data, it was possible to delineate the life histories of our subjects in considerable detail. Indeed, we were able to enumerate chronologically the addiction and criminal history of each interviewed subject. With respect to drug use, we classified each year of each subject's life as either addictedor abstinent from onset of opiate use to 1964. Each year was coded separately and classified as an addicted year or an abstinent year depending upon whether the addict was on or off opiates. If the subject was in prison for more than half of any given year, this year was classified as incarceration. Thus, three mutually exclusive types of years were designated: addicted, in prison, or abstinent. Each of the 1,434 years between onset and 1964 was coded in this manner.

Findings

The pre-addiction characteristics of this sample and the phenomenon of onset have been described elsewhere in some detail [ (2)] . It is pertinent to note here only that their marihuana smoking and subsequent opiate addiction began during early adolescence as a part of pre-oriented recreational behaviour. Drug use and street life had an appeal for these boys. The beginning of their addiction career seemed exciting, relatively innocuous, and subject to their personal control. What occurred after the onset of opiate addiction is the topic of the present analysis.

Addiction Status at Time of Interview

The 108 former addict patients were interviewed some 13 years after their onset of opiate use. Their mean age at this time was 33 years. It was found that 40 % of the subjects had used opiates during the entire three-year period prior to interview; another 19 % were imprisoned for part of the three-year period but otherwise used opiates; 8 % were not at risk at all with regard to addiction status as they were in prison all three years. Thus, two-thirds of the subjects were continually addicted or in prison during the last three-year period.

There were, then, 35 males who were not continually addicted and at risk during the last three years. Of these, 14 were off drugs for only one or two of the three years and 21 were entirely abstinent during this period. These latter 21 subjects were classified as cured on the basis of three consecutive years of abstinence prior to interview.

Inasmuch as the maturation hypothesis states a relationship either between years of drug use and abstinence, or between age and the cessation of drug use, it is necessary to control for years of use and chronological age. In table 1, the addicted subjects are classified by years since onset of opiate use and compared with the cured group. With respect to the three addicted groups, there is no evidence to support the interpretation that abstinence increases either with years of drug use or with the aging process itself. Thus, in Group 1 (4-9 years since onset) 93.2 % of their years were spent either addicted or in prison; 6.8 % were abstinent years. Similar results obtained with regard to Groups 2 and 3 -only 6.9 and 5.7 % of their total years since onset were abstinent.

Several comments are relevant with respect to the 21 males classified as cured. In the preliminary tabular analysis of the maturation data, all 108 subjects were combined and it appeared that abstinence increased somewhat with years of drug use. Further investigation of the table and case histories revealed, however, that a small group accounted for most of the abstinent years - over 72 % of all abstinence years (180 of 249 years) occurred among these 21 males. Furthermore, it became evident that there were in fact two dominant patterns of drug use: continuous use of opiates without periods of abstinence and continuous years of abstinence. Thus, 48 of the 87 who were not cured were never off drugs for as much as a year after onset; there were few odd years of abstinence. Conversely, once off drugs for 3 years, it was unlikely that the subject returned to drug use; there were only four instances of relapse following cure (that is, after 3 consecutive years of abstinence).

TABLE I Years spent addicted, in prison, and abstinent from onset of opiate use to 1964 for three addicted groups and one cured group

 

Years since onset spent:

 

Years since onset:

Addicted

In prison

Abstinent

Group

No. in group

Age at onset, mean

Range

Mean

No.

%

No.

%

No.

%

1. Addicted
31 18.5
4 - 9
7.1 177 80.8 27 12.3 15 6.8
2. Addicted
27 18.4
10 - 14
11.7 230 72.6 65 20.5 22 6.9
3. Addicted
29 19.8
15+
19.5 381 67.3 153 27.0 32 5.7
4. Cured
21 23.0   15.8 101 30.4 51 15.4 180 54.2
TOTAL
108 19.7   13.3 889 62.0 296 20.6 249 17.4

Criminality and Maturation

In his discussion of maturing out of narcotic addiction, Winick considered the probable relationship between drug use and criminal behaviour. Specifically, he noted that addiction was associated with criminality in that addicts tended to commit more crimes when using drugs than when abstinent. Two hypotheses seem pertinent in this regard: ( a) that opiate addiction increases criminality, and ( b) that criminal behaviour itself may be subject to the maturation process. But perhaps most relevant of all, can some more precise association between addiction and criminality be established? How likely is a person to be arrested, during the time that he is an addict? Do arrests increase or decrease with years of addiction?

For all 108 male addicts, arrest occurred once every four years while they were using drugs (table 2). While addicted, this likelihood of arrest remained quite stable; it varied only from 23 to 32 % among the four groups.

TABLE 2 Number of arrests while addicted and while abstinent for three addicted groups and one cured group

 

Addicted years

 

Abstinent years

 

Group

No. in group

Arrest

No arrest

% of yrs. with arrest

Arrest

No arrest

% of yrs. with arrest

1. Addicted
120 31 57 32.2 2 13 13.3
2. Addicted
166 27 64 27.8 1 21 4.5
3. Addicted
295 29 86 22.6 5 27 15.6
4. Cured
73 21 28 27.7 5 175 2.8
TOTAL
654 108 235 26.4 13 236 5.2

NOTE. - Difference in arrests while addicted vs. arrests while abstinent: X [ 2] = 50.8, P.001

During those years in which the subjects were abstinent, arrests were uncommon - only 5.2% of the 249 abstinent years were characterized by arrest. As might be expected, arrest was least probable among those who were cured - only 5 arrest years out of 180 abstinence years within this group.

Hypothesis 1 is confirmed. Addiction does increase criminality. On the basis of the present tabulation, it may be said that opiate addiction increases the probability of arrest by more than 5 times: (26.4:5.2 + 5.1).

Still, it might be argued that we have not controlled for maturation in considering criminality; we have only considered the effect of drug use on arrests. In table 3, the extent of criminality during the first 3 years after onset of opiate use is contrasted with criminality during the last 3 years for both addicted and cured subjects. The findings are rather unequivocal : there is no support for Hypothesis 2. The probability of arrest or incarceration is greater during the last three-year period than during the comparable first period. For all 108 subjects, the percentage who were arrested or imprisoned during the last three-year period increased over that of the first three-year period - from 44 to 61%. Comparing the addicted and cured groups, it is notable that recorded criminal behaviour has markedly increased among the 87 addicted males, while decreasing markedly among the cured males. Thus, in the post-onset period 58% of the addicted subjects were not arrested, but during the pre-interview period only 26 % were not arrested;

TABLE 3 Criminality during first three years following onset and during last three years for cured and addicted patients

 

All (N = 108)

Not cured (N = 87)

Cured (N = 21)

 

First 3 years after onset

Last 3 years before interview

First 3 years after onset

Last 3 years before interview

First 3 years after onset

Last 3 years before interview

Criminality during each three-year period

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

No Arrest
61 56.5 42 38.9 50 57.5 23 26.4 11 52.4 19 89.5
Arrested
35 32.4 30 27.8 31 35.6 29 33.3 4 19.0 1 4.8
In Prison
12 11.1 36 33.3 6 6.9 35 40.2 6 28.6 1 4.8
TOTAL
108 100.0 108 100.0 87 100.0 87 100.0 21 100.0 21 100.0

 

Addiction status at interview

Total males

Principal means of support

Using opiates (N = 87)%

cured (N = 21)%

No.

%

Steady employment
11.5 42.9 19 17.6
Irregular employment and some illegal income
33.3 33.3 36 33.3
Principally illegal income (theft, sale of drugs, etc)
48.3 14.3 45 41.7
Dependent on parents or relatives
6.9 9.5 8 7.4
TOTAL
100.0 100.0 108 100.0

TABLE 4 Principal means of support since leaving school for 108 male addicts

significantly, 40% were in prison during this last three-year period. Conversely, over 90% of the cured subjects were without arrest during the 3 years preceeding interview.

Principal Employment

Finally, in considering the life course of opiate addiction, we decided to independently consider the means of livelihood followed by our addict sample over the years. To this end, we separately coded the principal means of support since leaving school for each of the 108 males. The purpose of this classification was twofold. First, to consider and perhaps obviate the possibility that official records of criminality had biased our findings concerning maturation and crime. And second, to provide a more meaningful portrayal of the way of life followed by addicts on the street.

Almost half of the 108 males had been engaged principally or exclusively in criminal means of support during their entire adult lives (table 4). These 45 subjects were a varied group with respect to their success as criminals. Some were affluent, sophisticated and able to avoid arrest or incarceration. Others were unsuccessful criminals who spent much of their adult life in prison. Most were between these extremes of success or failure. Among the common means of illegal support favoured by these 45 criminal addicts were selling drugs, theft of property, procuring, and gambling.

Of the remaining 63 males, 36 pursued some illegal means of support but also worked irregularly, 8 were dependent upon their parents or relatives, and 19 were able to maintain steady legitimate employment. Thus, in the years since leaving school only 19 of the 108 men were able to maintain steady employment. Inasmuch as " steady employment " was designated as holding any job (or jobs) for more than half of the years since leaving school, the inability or unwillingness of these males to follow a legitimate career is notable.

In considering the maturation hypothesis with respect to the employment and criminal careers followed by these addicts, two comments seem pertinent. First, official records underestimate the extent of criminality and overestimate legitimate employment. Second, these conclusions from the life histories of addicts do not support the thesis that most opiate users mature out of their criminality. Indeed, there is further substantiation of the thesis that the life course of opiate addiction (unless abstinence is obtained), is toward greater social disability as the years go by.

Discussion

Two recent follow-up studies of opiate addicts are particularly relevant to the present findings concerning maturation (7,10). Vaillant has reported that 90% of 100 New York City male addicts relapsed to use of narcotics after their first Lexington hospitalization, but that 30% had been abstinent for 3 or more years at the time of follow-up. He also noted that these addicted subjects were usually unable to hold sustained employment, while two-thirds of the abstinent males found steady employment.

O'Donnell calculated the total years between Lexington discharge and follow-up for 212 Kentucky male addicts. He found that of 2,450 man-years lived until interview or death, 18% were abstinent, 19% institutionalized, 32% addicted, and 27% either occasional use of opiates or use of other drugs (4% of the total years were classified as unknown). O'Donnell's findings are strikingly similar to our own: of 1,434 man-years between onset and interview, 17.4 were abstinent years, 20.6 in prison, and 62.0% addicted (table 1). The greater decline in the addicted years observed for the Kentucky addicts as compared with the Puerto Rican addicts is probably due to the increasing difficulty of obtaining narcotics mentioned by O'Donnell.

The three follow-up studies of former Lexington patients - in New York City, Kentucky and Puerto Rico - substantiate the finding that can increasing number of opiate addicts become abstinent during their adult years. It appears that 20 to 40% become permanently abstinent by age 40. Maturation, then, is a fact for some one-third of these addicts. Given the difficulty of controlling for age, death and length of addiction, not to mention the ethnic differences of the three populations, the concurrence of the research findings are striking.

Conclusion

In our test of the maturation hypothesis, we have found that most of the Puerto Rican opiate addicts had not given up drugs - 67% were still using heroin, or were incarcerated, at time of follow-up. Furthermore, the extent of social impairment and criminality tended to increase, rather than decrease, over the years if drug use was continued. Conversely, it was found that a sizeable minority of opiate addicts do become abstinent, give up their criminal behaviour and become reasonably productive citizens. Of those who were classified as cured, almost half were steadily employed and 90% were arrest free during the last three years.

It appears, then, that two major patterns exist with respect to the life course of opiate addiction in the United States. In one instance, the addict becomes increasingly enmeshed in a non-productive or criminal career as his dependence upon opiates progresses into his adult years. In the second case, the addict terminates his drug-centred way of life and assumes, or re-establishes, a legitimate role in society. In this latter sense, it may be said that some one-third of opiate addicts mature out of their dependence upon drugs.

References

001

J. C. Ball and D. O. Pabon," Locating and Interviewing Narcotic Addicts in Puerto Rico ", Sociology and Social Research (1965) 49: 401-411.

002

J. C. Ball, " Marihuana Smoking and the Onset of Heroin Use ", The British Journal of Criminology (1967) 7: 408-413.

003

J. C. Ball, " The Reliability and Validity of Interview Data obtained from 59 Narcotic Drug Addicts ", The American Journal of Sociology (1967) 72: 650-654.

004

I. Chein, D. L. Gerard, R. S. Lee and E. Rosenfeld, The Road to H . New York, Basic Books, 1964.

005

J. P. Fort, " Heroin Addiction Among Young Men ", Psychiatry (1954) 17: 251-259.

006

A. R. Lindesmith, Addiction and Opiates , Chicago, Aldine Publishing Co., 1968.

007

J. A. O'Donnell, " Social Factors and Follow-up Studies in Opioid Addiction ", The Addictive States , Baltimore, Williams & Wilkins, 1968.

008

J. A. O'Donnel, Narcotic Addicts in Kentucky , Washington, D.C., U.S. Government Printing Office, in press, chapter 3.

009

G. E. Vaillant, " A Twelve-Year Follow-up of New York Narcotic Addicts : I. The Relation of Treatment to Out-come ", American Journal of Psychiatry (1966) 122: 727-737.

010

G. E. Vaillant, " A Twelve-Year Follow-up of New York Narcotic Addicts : II. The Natural History of a Chronic Disease ", New England Journal of Medicine (1966) 275: 1282-1288.

011

A. Wikler, " Conditioning Factors in Opiate Addiction and Relapse ", Narcotics, New York, McGraw-Hill, 1965.

012

C. Winick, " Maturing Out of Narcotic Addiction ", Bulletin on Narcotics (1962) 14: 1-7.